Nclex_Extracted_Pages_55_to_98 Respiratory Problems PDF

Adult—Respiratory UNIT XI Respiratory Problems of the Adult Client Pyramid to Success Health Promotion and Maintenance Educating the client about...

Adult—Respiratory UNIT XI Respiratory Problems of the Adult Client Pyramid to Success Health Promotion and Maintenance Educating the client about adequate uid and nutrition- The Pyramid to Success focuses on infectious dis- al intake eases and respiratory care in relation to respiratory Educating the client about breathing exercises and res- problems. Pyramid Points focus on the client with piratory therapy and care pneumonia, respiratory failure, chronic obstructive Educating the client about medication administration pulmonary disease, pneumothorax, inuenza, tuber- Educating the client about the need for follow-up care culosis, and COVID-19. Treatment of respiratory Educating the client about the prevention of transmis- problems including medications and other therapies, sion of infection adequate nutrition and rest to promote the healing Informing the client about health promotion programs process, and prevention of transmission and progres- Performing respiratory assessment techniques sion of the disease are discussed. Focus on assisting Preventing respiratory problems and infectious diseases the client to cope with the social isolation issues that Providing health screening related to risks for respira- exist during the period of illness and on teaching the tory problems client and family the critical measures of screening, Recognizing cues that indicate risk factors for a respira- preventing respiratory disease, and the prevention tory problem or infectious disease and transmission of infectious airborne and droplet diseases. Psychosocial Integrity Considering religious, cultural, and spiritual inuences when providing care Discussing body image changes related to respiratory Client Needs: Learning Outcomes problems Discussing end-of-life and grief and loss issues Safe and Effective Care Environment Discussing situational role changes Collaborating with the interprofessional team in the Identifying coping strategies management of the respiratory problem Identifying support systems and community resources Discussing consultations and referrals related to the res- Promoting support and comfort during times when so- piratory problem cial isolation is required Ensuring necessary isolation precautions are in effect and maintained Physiological Integrity Ensuring that informed consent related to invasive pro- Administering medications cedures has been obtained Evaluating the effectiveness of prescribed treatments Handling infectious materials such as sputum or body Managing respiratory illnesses and infectious diseases uids safely Monitoring for acid-base imbalances Maintaining condentiality Monitoring for alterations in body systems Maintaining respiratory precautions, standard precau- Monitoring for infectious diseases tions, and other precautions Providing nutrition and oral hygiene Prioritizing hypotheses based on client needs Taking action in emergency situations 679  CHAPTER 51 Adult—Respiratory Respiratory Problems Contributor: Jessica Grimm, DNP, APRN, ACNP-BC, CNE PRIORITY CONCEPTS Gas Exchange; Perfusion I. Anatomy and Physiology D. Lower respiratory airway A. Primary functions of the respiratory system 1. Trachea: Located in front of the esophagus; 1. Provides oxygen for metabolism in the tissues branches into the right and left mainstem bron- 2. Removes carbon dioxide, the waste product of chi at the carina metabolism 2. Mainstem bronchi B. Secondary functions of the respiratory system a. Begin at the carina 1. Facilitates sense of smell b. The right bronchus is slightly wider, shorter, 2. Produces speech and more vertical than the left bronchus. 3. Maintains acid–base balance c. Divide into secondary or lobar bronchi that 4. Maintains body water levels enter each of the ve lobes of the lung 5. Maintains heat balance d. The bronchi are lined with cilia, which propel C. Upper respiratory airway mucus up and away from the lower airway to 1. Nose: Humidies, warms, and lters inspired the trachea, where it can be expectorated or air swallowed. 2. Sinuses: Air-lled cavities within the hollow 3. Bronchioles bones that surround the nasal passages and pro- a. Branch from the secondary bronchi and sub- vide resonance during speech divide into the small terminal and respiratory 3. Pharynx bronchioles a. Passageway for the respiratory and digestive b. Contain no cartilage and depend on the elas- tracts located behind the oral and nasal cavi- tic recoil of the lung for patency ties c. The terminal bronchioles contain no cilia b. Divided into the nasopharynx, oropharynx, and do not participate in gas exchange. and laryngopharynx 4. Alveolar ducts and alveoli 4. Larynx a. Acinus (plural, acini) is a term used to indicate a. Located just below the pharynx at the root of all structures distal to the terminal bronchiole. the tongue; commonly called the voice box b. Branch from the respiratory bronchioles b. Contains two pairs of vocal cords, the false c. Alveolar sacs, which arise from the ducts, and true cords contain clusters of alveoli, which are the ba- c. The opening between the true vocal cords is sic units of gas exchange. the glottis. The glottis plays an important role d. Type 2 alveolar cells in the walls of the al- in coughing, which is the most fundamental veoli secrete surfactant, a phospholipid pro- defense mechanism of the lungs. tein that reduces the surface tension in the 5. Epiglottis alveoli; without surfactant, the alveoli would a. Leaf-shaped elastic ap structure at the top of collapse. the larynx 5. Lungs b. Prevents food from entering the tracheobron- a. Located in the pleural cavity in the thorax chial tree by closing over the glottis during b. Extend from just above the clavicles to the swallowing diaphragm, the major muscle of inspiration   CHAPTER 51 Respiratory Problems 681 c. The right lung, which is larger than the left, is BOX 51.1 Risk Factors for Respiratory Disorders divided into three lobes: the upper, middle, and lower lobes. Adult—Respiratory Chest injury d. The left lung, which is narrower than the Crowded living conditions right lung to accommodate the heart, is di- Environmental allergies vided into two lobes. Exposure to chemicals and environmental pollutants e. The respiratory structures are innervated by Family history of infectious disease the phrenic nerve, the vagus nerve, and the Frequent respiratory illnesses Geographical residence and travel to foreign countries thoracic nerves. Smoking f. The parietal pleura lines the inside of the tho- Surgery racic cavity, including the upper surface of the Use of chewing tobacco diaphragm. Viral syndromes g. The visceral pleura covers the pulmonary sur- faces. Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Saunders. h. A thin uid layer, which is produced by the cells lining the pleura, lubricates the visceral pleura and the parietal pleura, allowing them b. Assess the client’s ability to inhale and hold to glide smoothly and painlessly during res- their breath. piration. 3. Postprocedure: No special care is required after i. Blood ows throughout the lungs via the pul- the procedure unless there are abnormal nd- monary circulation system. ings. 6. Accessory muscles of respiration include the sca- lene muscles, which elevate the rst two ribs; the Question the client regarding pregnancy or the sternocleidomastoid muscles, which raise the possibility of pregnancy before performing radiography sternum; and the trapezius and pectoralis mus- studies. cles, which x the shoulders. 7. The respiratory process C. Sputum specimen a. The diaphragm descends into the abdominal 1. Description: Specimen obtained by expectora- cavity during inspiration, causing negative tion or tracheal suctioning to assist in the identi- pressure in the lungs. cation of organisms or abnormal cells (see Box b. The negative pressure draws air from the area 70.11 in Chapter 70) of greater pressure, the atmosphere, into the 2. Sputum for culture and sensitivity should be col- area of lesser pressure, the lungs. lected before antimicrobial therapy is initiated c. In the lungs, air passes through the terminal unless the test is being performed to evaluate the bronchioles into the alveoli and diffuses into effectiveness of medications already being given. surrounding capillaries, then travels to the 3. Preprocedure rest of the body to oxygenate the body tissues. a. Determine the specic purpose of collection, d. At the end of inspiration, the diaphragm and and check institutional policy for the appro- intercostal muscles relax and the lungs recoil. priate method for collection. e. As the lungs recoil, pressure within the lungs b. Obtain an early morning sterile specimen by becomes higher than atmospheric pressure, suctioning or expectoration after a respirato- causing the air, which now contains the cellu- ry treatment if a treatment is prescribed; give lar waste products carbon dioxide and water, the client the specimen cup the night before. to move from the alveoli in the lungs to the c. Instruct the client to rinse the mouth with atmosphere. water before collection to decrease contami- f. Effective gas exchange depends on distribu- nation of the sputum sample from particles tion of gas (ventilation) and blood (perfu- in the oropharynx. sion) in all portions of the lungs. d. Obtain 15 mL of sputum. e. Instruct the client to take several deep breaths II. Diagnostic Tests and then cough deeply to obtain sputum. Re- A. Risk factors for respiratory disorders (Box 51.1) mind the client that sputum comes from the B. Chest x-ray lm (radiograph) lungs and that saliva is not sputum. 1. Description: Provides information regarding the f. Collect the specimen before the client begins anatomical location and appearance of the lungs antibiotic therapy. If already started on anti- 2. Preprocedure biotic therapy, ensure that the laboratory can a. Remove all jewelry and other metal objects utilize an antimicrobial removal device when from the chest area. analyzing the specimen.  682 UNIT XI Respiratory Problems of the Adult Client 4. Postprocedure 2. Tissue samples are used for diagnosing and stag- a. If a culture of sputum is prescribed, transport ing lung cancer, detecting infections, and identi- the labeled specimen to the laboratory im- fying inammatory diseases that affect the lungs, Adult—Respiratory mediately; indicate whether the client was such as sarcoidosis. currently on antimicrobial therapy at the 3. Postprocedure, the client is monitored for signs time of collection. of bleeding and respiratory distress. b. Assist the client with mouth care. F. Pulmonary angiography 1. Description Ensure that an informed consent was obtained for a. A uoroscopic procedure in which a catheter any invasive procedure. Vital signs are measured before is inserted through the antecubital or femoral the procedure and monitored postprocedure to detect vein into the pulmonary artery or one of its signs of complications. branches b. Involves an injection of iodine or radiopaque D. Laryngoscopy and bronchoscopy contrast material 1. Description: Direct visual examination of the 2. Preprocedure larynx, trachea, and bronchi with a beroptic a. Assess for allergies to iodine, seafood, or oth- bronchoscope er radiopaque dyes. 2. Preprocedure b. Maintain NPO status as prescribed. a. Maintain NPO (nothing by mouth) status as c. Assess results of coagulation studies. prescribed. d. Establish an IV access. b. Assess the results of coagulation studies. e. Administer sedation as prescribed. c. Remove dentures and eyeglasses. f. Instruct the client to lie still during the proce- d. Instruct the client to perform good mouth dure. care to prevent bacteria from entering into g. Instruct the client that they may feel an urge the lungs from the oropharynx. to cough, ushing, nausea, or a salty taste fol- e. Establish an intravenous (IV) access as neces- lowing injection of the dye. sary, and administer medication for sedation h. Have emergency resuscitation equipment as prescribed. A local anesthetic spray may be available. used; instruct the client not to swallow the 3. Postprocedure spray and to expectorate any excess into a ba- a. Avoid taking blood pressures for 24 hours in sin. the extremity used for the injection. f. Have emergency resuscitation supplies read- b. Monitor peripheral neurovascular status of ily available. the affected extremity. 3. Postprocedure c. Assess insertion site for bleeding. a. Maintain the client in a semi-Fowler’s posi- d. Monitor for reaction to the dye. tion. e. Apply cold compresses to the puncture site to b. Assess for the return of the gag reex. reduce swelling or discomfort. c. Maintain NPO status until the gag reex re- G. Thoracentesis turns. 1. Description: Removal of uid or air from the d. Monitor for bloody sputum. pleural space via transthoracic aspiration e. Monitor respiratory status, particularly if se- 2. Preprocedure dation has been administered. a. Prepare the client for ultrasound or chest ra- f. Monitor for complications, such as bron- diograph, if prescribed, before the procedure. chospasm or bronchial perforation, indicat- b. Assess results of coagulation studies. ed by facial or neck crepitus, dysrhythmias, c. Note that the client is positioned sitting up- hemorrhage, hypoxemia, and pneumothorax. right, with the arms and shoulders supported g. Notify the primary health care provider by a table at the bedside during the procedure (PHCP) if signs of complications occur. (Fig. 51.1). h. Inform the client that warm saline gargles d. If the client cannot sit up, the client is placed and lozenges may be helpful for a sore throat. lying in bed toward the unaffected side, with i. Biopsy or culture results are available in 2 to the head of the bed elevated. 7 days. e. Instruct the client not to cough, breathe E. Endobronchial ultrasound (EBUS) deeply, or move during the procedure. 1. Tissue samples are obtained from central lung f. Administer cough suppressant as prescribed masses and lymph nodes, using a bronchoscope before the procedure if the client has a trou- with the help of ultrasound guidance. blesome cough.  CHAPTER 51 Respiratory Problems 683 b. An open lung biopsy is performed in the op- erating room. 2. Preprocedure Adult—Respiratory a. Maintain NPO status as prescribed. b. Inform the client that a local anesthetic will be used for a needle biopsy but that a sensa- tion of pressure during needle insertion and aspiration may be felt. c. Administer analgesics and sedatives as pre- scribed. d. Instruct client to remain still during the pro- cedure. FIG. 51.1 Positions for thoracentesis. 3. Postprocedure a. Apply a dressing to the biopsy site and moni- 3. Postprocedure tor for drainage or bleeding. a. Monitor respiratory status. b. Monitor for signs of respiratory distress, and b. Apply a pressure dressing, and assess the notify the PHCP if they occur. puncture site for bleeding and crepitus. c. Monitor for signs of pneumothorax and c. Monitor for signs of pneumothorax, air em- air emboli, and notify the PHCP if they bolism, and pulmonary edema. occur. d. Review chest x-ray results to monitor for d. Prepare the client for chest radiography if pneumothorax. prescribed. H. Pulmonary function tests J. Spiral (helical) computed tomography (CT) scan 1. Description: Tests used to evaluate lung mechan- 1. Frequently used test to diagnose pulmonary em- ics, gas exchange, and acid–base disturbance bolism through spirometric measurements, lung vol- 2. IV injection of contrast medium is used; if the cli- umes, and arterial blood gas levels ent cannot have contrast medium, a ventilation- 2. Preprocedure perfusion (V/Q) scan will be done. a. Determine whether an analgesic that may de- 3. The scanner rotates around the body, allowing press the respiratory function is being admin- for a three-dimensional picture of all regions of istered. the lungs. b. Consult with the PHCP regarding withhold- K. V/Q lung scan ing bronchodilators before testing, or alter- 1. Description natively whether the testing will be done a. The perfusion scan evaluates blood ow to prior to and after administration of a bron- the lungs. chodilator. b. The ventilation scan determines the patency c. Instruct the client to void before the proce- of the pulmonary airways and detects abnor- dure and to wear loose clothing. malities in ventilation. d. Remove dentures. c. A radionuclide may be injected for the proce- e. Instruct the client to refrain from smoking or dure. eating a heavy meal for 4 to 6 hours before d. Generally this is the preferred test to use with the test. renal impairment. f. Measure height and weight to determine pre- e. Encourage the client to drink uids to avoid dictive values. renal impairment. 3. Postprocedure: The client may resume a normal 2. Preprocedure diet and any bronchodilators and respiratory treat- a. Assess the client for allergies to dye, iodine, or ments that were withheld before the procedure. seafood. b. Remove jewelry around the chest area. Clients with severe respiratory problems are occa- c. Review breathing methods that may be re- sionally exhausted after the testing and will need rest. quired during testing. d. Establish an IV access. I. Lung biopsy e. Administer sedation if prescribed. 1. Description f. Have emergency resuscitation equipment a. A transbronchial biopsy and a transbronchial available. needle aspiration may be performed to ob- 3. Postprocedure tain tissue for analysis by culture or cytologi- a. Monitor the client for reaction to the radio- cal examination. nuclide.  684 UNIT XI Respiratory Problems of the Adult Client b. Instruct the client that the radionuclide clears BOX 51.2 Tuberculin Skin Test Procedure from the body in about 8 hours. c. Encourage increased uid intake to clear the 1. Determine hypersensitivity or previous reactions to skin Adult—Respiratory dye from the body if there is no uid restric- tests. tion. 2. Assess whether the client has received Bacille-Calmette- L. Computed tomography pulmonary angiography Guerin (BCG) in the past, which would demonstrate a 1. Description positive reaction. a. The scan visualizes the pulmonary arteries 3. Use a skin site that is free of excessive body hair, derma- titis, and blemishes. and blood ow. 4. Apply the injection at the upper third of the inner surface b. Its main use is to diagnose pulmonary embo- of the left arm. lism and is the preferred method. 5. Circle and mark the injection test site with indelible ink. c. A contrast dye is injected. 6. Document the date, time, and test site. 2. Preprocedure: Similar to the V/Q lung scan; in 7. Advise the client not to scratch the test site to prevent addition, renal function should be adequate, infection and possible abscess formation. and dosing of the contrast should be done by a 8. Instruct the client to avoid washing the test site. pharmacist. 9. Assess the reaction at the injection site 48 to 72 hours 3. Postprocedure: Similar to the V/Q lung scan after administration of the test antigen. M. Skin tests: A skin test uses an intradermal injection 10. Assess the test site for the amount of induration (hard to help diagnose various infectious diseases (Box swelling) in millimeters and for the presence of erythema and vesiculation (small blister-like elevations). 51.2). N. Arterial blood gases (ABGs) 1. Description: Measurement of the dissolved oxy- b. Pain with movement, deep breathing, and gen and carbon dioxide in the arterial blood coughing results in impaired ventilation and helps indicate the acid–base state and how well inadequate clearance of secretions. oxygen is being carried to the body. c. Can be serious and life-threatening when 2. Preprocedure and postprocedure care, normal three or more ribs are fractured, with preex- results, and analysis of results: See Chapter 9 isting disease (particularly cardiopulmonary disease), or for the elderly client Avoid suctioning the client before drawing an ABG 2. Assessment sample, because the suctioning procedure will deplete a. Pain and tenderness at the injury site that in- the client’s oxygen, resulting in inaccurate ABG results. creases with inspiration b. Shallow respirations O. Pulse oximetry: See Chapter 10 c. Client splints chest using a pillow as needed; P. D-dimer external splints are not recommended be- 1. A blood test that measures clot formation and cause they limit chest wall expansion. lysis that results from the degradation of brin d. Fractures noted on rib series x-ray 2. Helps diagnose (a positive test result) the pres- 3. Interventions ence of thrombus in conditions such as deep a. Note that the ribs usually reunite spontane- vein thrombosis, pulmonary embolism, or ously. stroke; it is also used to diagnose disseminated b. Client has a higher risk of developing pneu- intravascular coagulation (DIC) and to monitor monia after rib fractures. the effectiveness of treatment. c. Open reduction and internal xation of the 3. D-dimer has high sensitivity, low specicity for ribs (rib plating) may be done. diagnosing clot formation. d. Place the client in a Fowler’s position. 4. The normal D-dimer level is less than 50 ng/mL e. Administer pain medication as prescribed to (less than 3.0 mmol/L); normal brinogen is 60 maintain adequate ventilatory status. to 100 mg/dL (2.0 to 5.0 g/L). f. Monitor for increased respiratory distress. g. Instruct the client to self-splint with the III. Respiratory Treatments (see Chapter ) hands, arms, or a pillow. IV. Chest Injuries h. Prepare the client for an intercostal nerve A. Rib fracture block as prescribed if the pain is severe. 1. Description B. Flail chest a. Results from direct blunt chest trauma and 1. Description causes a potential for intrathoracic injury, a. Occurs from blunt chest trauma associated such as pneumothorax, hemothorax, or pul- with accidents, which may result in hemo- monary contusion thorax and rib fractures  CHAPTER 51 Respiratory Problems 685 b. The loose segment of the chest wall becomes Outside air paradoxical to the expansion and contraction enters because of disruption of of the rest of the chest wall. Adult—Respiratory chest wall and 2. Assessment parietal pleura a. Paradoxical respirations (inward movement Normal of a segment of the thorax during inspiration lung with outward movement during expiration) b. Severe pain in the chest Chest Lung air enters c. Dyspnea wall because of d. Cyanosis disruption of visceral pleura e. Tachycardia Pleural f. Hypotension space g. Tachypnea, shallow respirations h. Diminished breath sounds Diaphragm Mediastinum 3. Interventions FIG. 51.2 Pneumothorax. Air in the pleural space causes the lungs to a. Maintain the client in a Fowler’s position if collapse around the hilus and may push the mediastinal contents (heart cervical spine injury has been ruled out. and great vessels) toward the other lung. b. Administer oxygen as prescribed. c. Monitor for increased respiratory distress. D. Pneumothorax (Fig. 51.2) d. Encourage coughing and deep breathing. 1. Description e. Administer pain medication as prescribed. a. Accumulation of atmospheric air in the pleu- f. Maintain bed rest and limit activity to reduce ral space, which results in a rise in intratho- oxygen demands. racic pressure and reduced vital capacity, or g. Open reduction and internal xation of the the greatest amount of air expired from the ribs (rib plating) may be done. lungs after taking a deep breath h. Prepare for intubation with mechanical ven- b. The loss of negative intrapleural pressure re- tilation, with positive end-expiratory pressure sults in collapse of the lung. (PEEP) for severe ail chest associated with c. A spontaneous pneumothorax occurs with respiratory failure and shock (see Chapter the rupture of a pulmonary bleb, or small air- 70). containing spaces deep in the lung. C. Pulmonary contusion d. An open pneumothorax occurs when an 1. Description opening through the chest wall allows the a. Characterized by interstitial hemorrhage entrance of positive atmospheric air pressure associated with intra-alveolar hemorrhage, into the pleural space. resulting in decreased pulmonary compli- e. A tension pneumothorax occurs from a blunt ance chest injury or from mechanical ventilation b. The major complication is acute respiratory with PEEP when a buildup of positive pres- distress syndrome. sure occurs in the pleural space. 2. Assessment 2. Assessment (Box 51.3) a. Dyspnea 3. Interventions b. Restlessness a. Diagnosis of pneumothorax is made by chest c. Increased bronchial secretions x-ray, which will show air or uid in the pleu- d. Hypoxemia ral space and reduction of lung volume. e. Hemoptysis b. Apply a nonporous dressing over an open f. Decreased breath sounds chest wound. g. Crackles and wheezes c. Administer oxygen as prescribed. 3. Interventions d. Place the client in a Fowler’s position for a. Maintain a patent airway and adequate venti- chest trauma. lation. e. Prepare for chest tube placement, which will b. Place the client in a Fowler’s position. remain in place until the lung has expanded c. Administer oxygen as prescribed. fully. d. Monitor for increased respiratory distress. f. Monitor the chest tube drainage system. e. Maintain bed rest and limit activity to reduce g. Monitor for subcutaneous emphysema. oxygen demands. h. Review serial chest x-ray results to determine f. Provide oxygen and give uids as prescribed. effectiveness of treatment. g. Prepare for mechanical ventilation with PEEP i. See Chapter 70 for information on caring for if required. a client with chest tubes.  686 UNIT XI Respiratory Problems of the Adult Client BOX 51.3 Assessment Findings: Pneumothorax Triggers* Allergens Infection Adult—Respiratory Absent or markedly decreased breath sounds on affected Exercise Irritants side Cyanosis Decreased chest expansion unilaterally Distended neck veins IgE–mast cell mediated response Dyspnea Hypotension Sharp chest pain Release of mediators from mast cells, Subcutaneous emphysema as evidenced by crepitus on eosinophils, macrophages, lymphocytes palpation Sucking sound with open chest wound Tachycardia Early-phase response Late-phase response Tachypnea Tracheal deviation to the unaffected side with tension Peaks in pneumothorax 30 to 60 minutes Peaks in 5 to 6 hours Bronchial smooth muscle constriction* Clients with a respiratory disorder should be posi- Mucosal edema Mucus secretion Bronchial hyperreactivity tioned with the head of the bed elevated. Infiltration with eosinophils Vascular leakage and neutrophils V. Asthma (Fig. .) Inflammation* A. Description Within 1. Chronic inammatory disorder of the airways 1 to 2 days that causes varying degrees of obstruction in the airways Infiltration with monocytes and lymphocytes 2. Marked by airway inammation and hyperre- sponsiveness to a variety of stimuli or triggers (Box 51.4). 3. Causes recurrent episodes of wheezing, breath- Air trapping lessness, chest tightness, and coughing associ- Hypoxemia Obstruction of large and small airways ated with airow obstruction that may resolve Respiratory acidosis spontaneously; it is often reversible with treat- ment. FIG. 51.3 Pathophysiology in asthma. Stems with asterisks are primary 4. Severity is classied based on the clinical fea- processes. IgE, Immunoglobulin E. tures before treatment. 5. Status asthmaticus is a severe life-threatening asthma episode that is refractory to treatment 9. Pulsus paradoxus and may result in pneumothorax, acute cor pul- 10. Diaphoresis monale, or respiratory arrest. 11. Cyanosis 6. Refer to Chapter 36 for additional information 12. Decreased oxygen saturation on asthma. 13. Pulmonary function test results that demon- strate decreased airow rates Silent breath sounds are associated with acute C. Interventions asthma exacerbation, may indicate impending respira- 1. Monitor vital signs. tory failure due to diuse bronchospasm, and represent 2. Monitor pulse oximetry. a life-threatening condition. 3. Monitor peak ow. 4. Administer bronchodilators and corticosteroids B. Assessment as prescribed. 1. Restlessness 5. Educate the client and family on reducing stress 2. Wheezing or crackles and anxiety and avoiding environmental trig- 3. Absent or diminished lung sounds gers. 4. Hyperresonance 6. During an acute asthma episode, provide inter- 5. Use of accessory muscles for breathing ventions to assist with breathing (Box 51.5). 6. Tachypnea with hyperventilation D. Client education 7. Prolonged exhalation 1. Discuss the intermittent nature of symptoms 8. Tachycardia and the need for long-term management.  CHAPTER 51 Respiratory Problems 687 BOX 51.4 Asthma Triggers BOX 51.5 Nursing Interventions During an Acute Asthma Episode Adult—Respiratory Environmental Factors Animal dander Position the client in a high-Fowler’s position or sitting to Cockroaches aid in breathing. Cold, dry air Administer oxygen as prescribed. Dust mites Stay with the client to decrease anxiety. Exhaust fumes Administer bronchodilators and other nebulizer treat- Fireplaces ments as prescribed. Molds Record the color, amount, and consistency of sputum, if Perfumes or other products with aerosol sprays any. Pollen Administer corticosteroids as prescribed. Smoke, including cigarette or cigar smoke Administer magnesium sulfate as prescribed. Sudden weather changes Administer intravenous uids as prescribed. Auscultate lung sounds before, during, and after treat- Physiological Factors ments. Exercise Gastroesophageal reux disease (GERD) Hormonal changes Sinusitis 2. Chronic obstructive pulmonary disease is a dis- Stress Viral upper respiratory infection ease state characterized by airow obstruction. 3. Chronic bronchitis and emphysema are progres- Medications sive lung diseases that fall under the general cat- Acetylsalicylic acid (aspirin) egory of chronic obstructive pulmonary disease. β-Adrenergic blockers 4. Chronic bronchitis is a condition in which the Nonsteroidal antiinammatory drugs bronchial tubes become inamed and excessive Occupational Exposure Factors mucus production occurs as a result of irritants Agriculture or injury. Industrial chemicals and plastics 5. Emphysema is a condition in which the air sacs Metal salts in the lungs are damaged and enlarged, resulting Pharmaceutical drugs in hyperination and breathlessness. Wood and vegetable dusts 6. Progressive airow limitation occurs, associated Food Additives with an abnormal inammatory response of the Beer, wine, dried fruit, shrimp, processed potatoes lungs that is not completely reversible. Monosodium glutamate 7. Chronic obstructive pulmonary disease (COPD) Sultes (bisultes and metabisultes) leads to pulmonary insufciency, pulmonary hy- Tartrazine pertension, and cor pulmonale. B. Assessment Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. 1. Cough (11th ed.). St. Louis: Mosby. pp. 542-543. 2. Exertional dyspnea 3. Wheezing and crackles 4. Sputum production 2. Identify possible triggers and measures to pre- 5. Weight loss vent episodes. 6. Barrel chest (emphysema) (Fig. 51.4) 3. Use pursed-lip breathing before, during, and af- 7. Use of accessory muscles for breathing ter activities that are possible triggers. 8. Prolonged expiration 4. Management of medication and proper admin- 9. Orthopnea istration 10. Cyanosis 5. Correct use of a peak owmeter and aero- 11. Delayed capillary rell chamber or “spacer” use with inhaler 12. Finger clubbing 6. Wear a MedicAlert bracelet. 13. Cardiac dysrhythmias 7. Develop an asthma action plan with the PHCP 14. Congestion and hyperination seen on chest x- and what to do if an asthma episode occurs. ray (Fig. 51.5) 15. ABG levels that indicate respiratory acidosis VI. Chronic Obstructive Pulmonary Disease with or without compensation and hypoxemia. A. Description Uncompensated respiratory acidosis in a COPD 1. Also known as chronic obstructive lung disease patient generally indicates an acute exacerba- and chronic airow limitation tion of COPD.  688 UNIT XI Respiratory Problems of the Adult Client 16. Pulmonary function tests that demonstrate de- 7. Suction the client’s lungs, if necessary, to clear creased vital capacity the airway and prevent infection. C. Interventions 8. Monitor weight. Adult—Respiratory 1. Monitor vital signs. 9. Encourage small, frequent meals to maintain 2. Administer a concentration of oxygen based on nutrition and prevent dyspnea. ABG values and oxygen saturation by pulse oxi- 10. Provide a high-calorie, high-protein diet with metry as prescribed. supplements. 3. Monitor pulse oximetry. 11. Encourage uid intake up to 3000 mL/day to 4. Provide respiratory treatments and chest physi- keep secretions thin, unless contraindicated. otherapy (CPT). 12. Place the client in a Fowler’s position and lean- 5. Instruct the client in diaphragmatic or abdomi- ing forward to aid in breathing (Fig. 51.6). nal breathing techniques, tripod positioning, 13. Allow activity as tolerated; include exercise and pursed-lip breathing techniques, which conditioning and pulmonary rehabilitation to increase airway pressure and keep air passages prevent muscle deconditioning; assess physical open, promoting maximal carbon dioxide expi- limitations and develop an activity plan based ration. on limitations. 6. Record the color, amount, and consistency of 14. Administer bronchodilators and other nebuliz- sputum. er treatments as prescribed, and instruct the cli- ent in the use of oral and inhalant medications. 15. Administer corticosteroids as prescribed for ex- acerbations. 16. Administer mucolytics as prescribed to thin se- cretions. 17. Administer antibiotics for infection if pre- scribed. D. Client education (Box 51.6) VII.Pneumonia A. Description 1. Infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchi- oles 2. The edema associated with inammation stiff- ens the lung, decreases lung compliance and vi- tal capacity, and causes hypoxemia. 3. Pneumonia can be community-acquired or hospital-acquired. FIG. 51.4 Typical barrel chest in a client with chronic obstructive pulmo- 4. The chest x-ray lm shows lobar or segmental nary disease. consolidation, or pulmonary inltrates. Normal Chronic Obstructive Pulmonary Disease Normal Hyperinflation lung inflation of lungs Normal diaphragm Flattened curvature diaphragm FIG. 51.5 Diaphragm shape and lung ination in the normal client and in the client with chronic obstructive pulmonary disease.  CHAPTER 51 Respiratory Problems 689 Adult—Respiratory Sitting on the edge of a Sitting in a chair with the feet spread bed with the arms folded shoulder-width apart and leaning and placed on two or three forward with the elbows on the knees. pillows positioned over a Arms and hands are relaxed. nightstand. FIG. 51.6 Orthopnea positions that clients with chronic obstructive pulmonary disease can assume to ease the work of breathing. 8. Cyanosis, especially around the mouth or con- BOX 51.6 Client Education: Chronic Obstructive junctiva Pulmonary Disease 9. Mental status changes Adhere to activity limitations, alternating rest periods with 10. Sputum production, hemoptysis activity. C. Interventions Avoid eating gas-producing foods, spicy foods, and ex- 1. Administer oxygen as prescribed. tremely hot or cold foods. 2. Monitor respiratory status. Avoid exposure to individuals with infections, and avoid 3. Monitor for labored respirations, cyanosis, and crowds. cold and clammy skin. Avoid extremes in temperature. 4. Encourage coughing and deep breathing and Avoid replaces, pets, feather pillows, and other environ- use of the incentive spirometer. mental allergens. Avoid powerful odors. 5. Place the client in a semi-Fowler’s position to Meet nutritional requirements. facilitate breathing and lung expansion. Receive immunizations as recommended. 6. Change the client’s position frequently and am- Recognize the signs and symptoms of respiratory infection bulate as tolerated to mobilize secretions. and hypoxia. 7. Provide CPT (see Chapter 70). Stop smoking. 8. Perform nasotracheal suctioning if the client is Use medications and inhalers and/or nebulizers as pre- unable to clear secretions. scribed. 9. Monitor pulse oximetry. Use oxygen therapy as prescribed. 10. Monitor and record color, consistency, and Use pursed-lip and diaphragmatic or abdominal breath- amount of sputum. ing. 11. Provide a high-calorie, high-protein diet with When dusting, use a wet cloth. small frequent meals. 12. Monitor intake and output. 13. Encourage uids, up to 3 L/day, to thin secre- 5. A sputum culture identies the organism. tions unless contraindicated. 6. The white blood cell count, procalcitonin, and 14. Provide a balance of rest and activity, increasing the erythrocyte sedimentation rate are elevated. activity gradually. B. Assessment 15. Administer antibiotics as prescribed. 1. Chills 16. Administer antipyretics, bronchodilators, cough 2. Elevated temperature, other vital sign abnor- suppressants, mucolytic agents, and expecto- malities rants as prescribed. 3. Pleuritic pain 17. Prevent the spread of infection by handwashing 4. Myalgia and the proper disposal of secretions. 5. Tachypnea, tachycardia D. Client education 6. Rhonchi and wheezes 1. About the importance of rest, proper nutrition, 7. Use of accessory muscles for breathing, dyspnea and adequate uid intake  690 UNIT XI Respiratory Problems of the Adult Client 2. To avoid chilling and exposure to individuals e. Muscle or body aches with respiratory infections or viruses f. Headache 3. To avoid smoke exposure g. New loss of taste or smell Adult—Respiratory 4. Regarding medications and the use of inhalants h. Sore throat as prescribed i. Congestion or runny nose 5. To notify the PHCP if chills, fever, dyspnea, hem- j. Nausea or vomiting optysis, or increased fatigue occurs k. Diarrhea 6. To receive a pneumococcal vaccine as recom- 2. Emergency care should be sought if the person mended by the PHCP; refer to Chapter 19 and is having difculty breathing, experiences per- the following website for information about this sistent pain or pressure in the chest, if the per- vaccine: http://www.cdc.gov/vaccines/vpd-vac/p son experiences new confusion, is unable to stay neumo/default.htm awake, or if cyanosis develops. C. Transmission and prevention Teach clients that using proper handwashing tech- 1. COVID-19 may be spread by people who are not niques, disposing of respiratory secretions properly, and showing symptoms. receiving vaccines will assist in preventing the spread of 2. Transmission is from person to person and infection. via contact with the virus via respiratory drop- lets produced when an infected person coughs, VIII. Severe Acute Respiratory Syndrome (SARS) sneezes, or talks. A. Respiratory illness caused by the coronavirus called 3. These droplets can land in the mouths or noses SARS-associated coronavirus of people who are nearby or possibly be inhaled B. The syndrome begins with a fever, an overall feel- into the lungs. ing of discomfort, body aches, and mild respiratory 4. Droplet precautions and possibly contact pre- symptoms. cautions are necessary. C. After 2 to 7 days, the client may develop a dry cough 5. Prevention includes avoiding crowds; maintain- and dyspnea. ing 6 feet of social distancing, especially from D. Infection is spread by close person-to-person contact sick people; handwashing; the use of hand sani- or by direct contact with infectious material (respira- tizer; wearing masks; coughing and sneezing tory secretions from infected persons or contact with into the elbow; keeping the hands away from the objects contaminated with infectious droplets). face; and keeping frequently touched surfaces E. Prevention includes avoiding contact with those sus- cleaned and sanitized daily. pected of having SARS, avoiding travel to countries 6. Prophylactic treatment may be recommended where an outbreak of SARS exists, avoiding close con- for those exposed to coronavirus and may in- tact with crowds in areas where SARS exists, and fre- clude selected vitamins and minerals, antiviral quent handwashing if in an area where SARS exists. medication, and immune system booster sup- plements; the person should not begin any pro- IX. COVID- (Coronavirus) phylactic treatment unless recommended by the A. Description primary health care provider. 1. SARS-CoV-2 is the coronavirus that causes COV- 7. All eligible individuals are highly encouraged ID-19. to receive the coronavirus vaccine and recom- 2. Older adults and people who have severe under- mended boosters to protect self and others from lying medical conditions such as heart or lung contracting the virus. disease or diabetes are at higher risk for develop- D. Treatment ing more serious complications from COVID-19 1. Varies depending on the clinical presentation illness. 2. The person needs to report symptoms imme- B. Symptoms diately if coronavirus is suspected and seek 1. People with COVID-19 have had a wide range treatment from the primary health care pro- of symptoms reported, ranging from mild symp- vider. toms to severe illness. Symptoms may appear 2 3. The primary health care provider will prescribe to 14 days after exposure to the virus. Symptoms treatment based on the most current CDC guide- can include the following: lines for treating coronavirus. a. Fever or chills 4. For additional information, refer to the Centers b. Cough for Disease Control and Prevention: Coronavirus c. Shortness of breath or difculty breathing 2019 (COVID-19): https://www.cdc.gov/coronavirus/ d. Fatigue 2019-ncov/faq.html  CHAPTER 51 Respiratory Problems 691 X. Inuenza E. Client education A. Description 1. Thoroughly wash hands especially after blow- 1. Also known as the u; highly contagious acute ing nose, sneezing, coughing, rubbing eyes, or Adult—Respiratory viral respiratory infection touching face. 2. May be caused by several viruses, usually known 2. Avoid crowded places; stay home if not feeling as types A, B, and C well. 3. Yearly vaccination is recommended to prevent 3. Cover mouth with tissue when sneezing or the disease, especially for those older than 50 coughing. years of age, individuals with chronic illness or 4. Cough or sneeze in the upper sleeve rather than who are immunocompromised, those living in in the hand. institutions, and health care personnel provid- ing direct care to clients (the vaccination is con- XI. Legionnaire’s Disease traindicated in the individual with egg allergies). A. Description 4. Additional prevention measures include avoid- 1. Acute bacterial infection caused by Legionella ing those who have developed inuenza, fre- pneumophila quent and proper handwashing, and cleaning 2. Sources of the organism include contaminated and disinfecting surfaces that have become con- cooling tower water and warm stagnant water taminated with secretions. supplies, including water vaporizers, water soni- 5. Avian inuenza A (H5N1) cators, whirlpool spas, and showers. a. Affects birds; does not usually affect humans; 3. Person-to-person contact does not occur; the however, human cases have been reported in risk for infection is increased by the presence of some countries. other conditions. b. An H5N1 vaccine has been developed for use B. Assessment: Inuenza-like symptoms with a high fe- if a pandemic virus were to emerge. ver, chills, muscle aches, and headache that may pro- c. Reported symptoms are similar to those as- gress to dry cough, pleurisy, and sometimes diarrhea sociated with inuenza types A, B, and C. C. Interventions: Treatment is supportive, and antibiot- d. Prevention measures include thorough ics may be prescribed. cooking of poultry products, avoiding con- tact with wild animals, frequent and proper XII. Pleural Eusion handwashing, and cleaning and disinfect- A. Description ing surfaces that have become contaminated 1. Pleural effusion is the collection of uid in the with secretions. pleural space. 6. Swine (H1N1) inuenza 2. Any condition that interferes with secretion or a. A strain of u that consists of genetic materi- drainage of this uid will lead to pleural effu- als from swine, avian, and human inuenza sion. viruses B. Assessment b. Signs and symptoms are similar to those that 1. Pleuritic pain that is sharp and increases with in- present with seasonal u; in addition, vomit- spiration ing and diarrhea commonly occur. 2. Progressive dyspnea with decreased movement c. Prevention measures and treatment are the of the chest wall on the affected side same as for the seasonal u. 3. Dry, nonproductive cough caused by bronchial B. Refer to Chapter 19 for information on vaccines. irritation C. Assessment 4. Tachycardia 1. Acute onset of fever, chills, and muscle aches 5. Elevated temperature 2. Headache 6. Decreased breath sounds and/or pleural friction 3. Fatigue, weakness, anorexia rub over affected area/side 4. Sore throat, cough, and rhinorrhea 7. Chest x-ray lm or CT scan that shows pleural D. Interventions effusion and a mediastinal shift away from the 1. Encourage rest. uid if the effusion is more than 250 mL 2. Encourage uids to prevent pulmonary compli- C. Interventions cations (unless contraindicated). 1. Identify and treat the underlying cause. 3. Monitor lung sounds. 2. Monitor breath sounds. 4. Provide supportive therapy such as antipyretics 3. Place the client in a Fowler’s position. or antitussives as indicated. 4. Encourage coughing and deep breathing. 5. Administer antiviral medications as prescribed 5. Prepare the client for thoracentesis. for the current strain of inuenza (see Chapter 6. If pleural effusion is recurrent, prepare the client 52). for pleurectomy or pleurodesis as prescribed.  692 UNIT XI Respiratory Problems of the Adult Client D. Pleurectomy B. Assessment 1. Consists of surgically stripping the parietal pleu- 1. Knifelike pain aggravated on deep breathing and ra away from the visceral pleura dry cough Adult—Respiratory 2. This produces an intense inammatory reaction 2. Dyspnea that promotes adhesion formation between the 3. Pleural friction rub heard on auscultation two layers during healing. C. Interventions E. Pleurodesis 1. Identify and treat the cause. 1. Involves the instillation of a sclerosing substance 2. Monitor lung sounds. into the pleural space via a thoracotomy tube 3. Administer analgesics as prescribed. 2. The substance creates an inammatory response 4. Apply hot or cold applications as prescribed. that scleroses tissue together. 5. Encourage coughing and deep breathing. 6. Instruct the client to lie on the affected side to XIII. Empyema splint the chest. A. Description 1. Collection of pus within the pleural cavity XV. Pulmonary Embolism 2. The uid is thick, opaque, and foul-smelling. A. Description 3. The most common cause is pulmonary infection 1. Occurs when a thrombus forms (most common- and lung abscess caused by thoracic surgery or ly in a deep vein), detaches, travels to the right chest trauma, in which bacteria are introduced side of the heart, and then lodges in a branch of directly into the pleural space. the pulmonary artery 4. Treatment focuses on treating the infection, 2. May be classied as massive, submassive, or low- emptying the empyema cavity, reexpanding the risk pulmonary embolism lung, and controlling the infection. 3. Clients prone to pulmonary embolism are those B. Assessment at risk for deep vein thrombosis, including those 1. Recent febrile illness or trauma with prolonged immobilization, surgery, obesi- 2. Chest pain ty, pregnancy, heart failure, advanced age, a his- 3. Cough tory of thromboembolism, or a client who takes 4. Dyspnea an estrogen-containing therapy. 5. Anorexia and weight loss 4. Fat emboli can occur as a complication follow- 6. Malaise ing fracture of a long bone and can cause pulmo- 7. Elevated temperature and chills nary emboli. 8. Night sweats 5. Treatment is aimed at prevention through risk 9. Pleural exudate on chest x-ray factor recognition and elimination. C. Interventions B. Assessment (Box 51.7) 1. Monitor breath sounds. C. Interventions (see Clinical Judgment: Take Action 2. Place the client in a semi-Fowler’s or high- Box) Fowler’s position. 3. Encourage coughing and deep breathing. 4. Administer antibiotics as prescribed. 5. Instruct the client to splint the chest as necessary. 6. Assist with thoracentesis or chest tube insertion BOX 51.7 Assessment Findings: Pulmonary to promote drainage and lung expansion. Embolism 7. If marked pleural thickening occurs, prepare the Apprehension and restlessness client for decortication, if prescribed; this surgi- Blood-tinged sputum, hemoptysis cal procedure involves removal of the restrictive Chest pain mass of brin and inammatory cells. Cough Crackles and wheezes on auscultation XIV. Pleurisy Cyanosis A. Description Diaphoresis 1. Inammation of the visceral and parietal mem- Distended neck veins branes; may be caused by pulmonary infarction Dyspnea accompanied by anginal and pleuritic pain, exac- or pneumonia erbated by inspiration Feeling of impending doom 2. The visceral and parietal membranes rub togeth- Hypotension er during respiration and cause pain. Petechiae over the chest and axilla 3. Pleurisy usually occurs on one side of the chest, Shallow respirations, increased respiratory rate usually in the lower lateral portions in the chest Tachypnea and tachycardia wall.  CHAPTER 51 Respiratory Problems 693 8. Monitor for nephrotoxicity from fungicidal CLINICAL JUDGMENT: TAKE medications. 9. Instruct the client to wear a mask and spray the Adult—Respiratory ACTION oor with water before sweeping a barn or chick- The nurse is caring for a client 2 days postoperative. The en coop. client has a history of deep vein thrombosis and heart failure. The client also has diculty with mobility and is obese. XIX. Sarcoidosis The client calls the nurse and reports sudden chest pain, A. Description a cough, and diculty breathing. The client is anxious and 1. Presence of epithelioid cell tubercles in the lung restless. Respirations are 26 breaths per minute and shallow. 2. The cause is unknown, but a high titer of Epstein- Pulse is 120 beats per minute. Blood pressure is 90/66 mm Barr virus may be noted. Hg. Pulse oximetry reading is 89%. Crackles are heard on auscultation of the lungs. The nurse suspects the devel- B. Assessment opment of pulmonary embolism and takes the following 1. Night sweats actions: 2. Chest pain 3. Fever Reassures the client and elevates the head of the bed 4. Weight loss Noties the Rapid Response Team and the PHCP 5. Cough and dyspnea Administers oxygen Prepares to obtain an arterial blood gas 6. Skin nodules Prepares for laboratory studies to be drawn and diagnos- 7. Polyarthritis tic scanning 8. Kveim test: Sarcoid node antigen is injected in- Prepares for the administration of heparin therapy or tradermally and causes a local nodular lesion in other therapies about 1 month. Monitors vital signs and checks lung sounds C. Interventions Provides comfort and emotional support 1. Administer corticosteroids to control symptoms. Documents the event, interventions taken, and the cli- 2. Monitor temperature. ent’s response to treatment 3. Increase uid intake. 4. Provide frequent periods of rest. 5. Encourage small, frequent, nutritious meals. XVI. Lung Cancer and Laryngeal Cancer: See Chapter  for more information. XX. Occupational Lung Disease A. Description XVII. Carbon Monoxide Poisoning: See Chapter  for 1. Caused by exposure to environmental or occu- more information. pational fumes, dust, vapors, gases, bacterial or fungal antigens, and allergens; can result in acute XVIII. Histoplasmosis reversible effects or chronic lung disease A. Description 2. Common disease classications include occupa- 1. Pulmonary fungal infection caused by spores of tional asthma pneumoconiosis (silicosis or coal Histoplasma capsulatum miner’s [black lung] disease), diffuse interstitial 2. Transmission occurs by the inhalation of spores, brosis (asbestosis, talcosis, berylliosis), or ex- which commonly are found in contaminated trinsic allergic alveolitis (farmer’s lung, bird fan- soil. cier’s lung, or machine operator’s lung). 3. Spores also are usually found in bird droppings. B. Assessment: Manifestations depend on the type of B. Assessment disease and respiratory symptoms. 1. Similar to pneumonia C. Interventions 2. Positive skin test for histoplasmosis 1. Prevention through the use of respiratory protec- 3. Positive agglutination test tive devices 4. Splenomegaly, hepatomegaly 2. Treatment is based on the symptoms experi- C. Interventions enced by the client. 1. Administer oxygen as prescribed. 2. Monitor breath sounds. XXI. Tuberculosis 3. Administer antiemetics, antihistamines, antipy- A. Description retics, and corticosteroids as prescribed. 1. Highly communicable disease caused by Myco- 4. Administer fungicidal medications as prescribed. bacterium tuberculosis 5. Encourage coughing and deep breathing. 2. M. tuberculosis is a nonmotile, nonsporulating, 6. Place the client in a semi-Fowler’s position. acid-fast rod that secretes niacin; when the bacil- 7. Monitor vital signs. lus reaches a susceptible site, it multiplies freely.  694 UNIT XI Respiratory Problems of the Adult Client 3. Because M. tuberculosis is an aerobic bacterium, BOX 51.8 Risk Factors for Tuberculosis it primarily affects the pulmonary system, espe- cially the upper lobes, where the oxygen content Adult—Respiratory Child younger than 5 years of age is highest, but it also can affect other areas of the Drinking unpasteurized milk if the cow is infected with bo- body, such as the brain, intestines, peritoneum, vine tuberculosis kidney, joints, and liver. Homeless individuals or those from a lower socioeconom- 4. An exudative response causes a nonspecic ic group, minority group, or refugee group pneumonitis and the development of granulo- Individuals in constant, frequent contact with an untreated or undiagnosed individual mas in the lung tissue. Individuals living in crowded areas, such as long-term care 5. Tuberculosis has an insidious onset, and many facilities, prisons, and mental health facilities clients are not aware of symptoms until the dis- Older client ease is well advanced. Individuals with malnutrition, infection, immune dysfunc- 6. Improper or noncompliant use of treatment pro- tion, or human immunodeciency virus infection; or im- grams may cause the development of mutations munosuppressed as a result of medication therapy in the tubercle bacilli, resulting in a multidrug- Individuals who abuse alcohol or are intravenous drug us- resistant strain of tuberculosis (MDR-TB). ers 7. The goal of treatment is to prevent transmission, History of past exposure, travel to other countries control symptoms, and prevent progression of the disease. B. Risk factors (Box 51.8) 3. Recent history of inuenza, pneumonia, febrile C. Transmission illness, cough, or foul-smelling sputum produc- 1. Via the airborne route by droplet infection tion 2. When an infected individual coughs, laughs, 4. Previous tests for tuberculosis; results of the test- sneezes, or sings, droplet nuclei containing tu- ing berculosis bacteria enter the air and may be in- 5. Recent bacillus Calmette-Guérin (BCG) vaccine (a haled by others. vaccine containing attenuated tubercle bacilli 3. Identication of those in close contact with the that may be given to persons in foreign coun- infected individual is important so that they can tries or to persons traveling to foreign countries be tested and treated as necessary. to produce increased resistance to tuberculosis) 4. When contacts have been identied, these persons are assessed with a tuberculin skin test and chest An individual who has received a BCG vaccine will x-rays to determi